1. U07-801 #816332110 Severe nephrotic syndrome with rising creatinine

2. 64 yo male of Indian descent with nephrotic syndrome, microscopic hematuria, and ARF (sCr 250) PMhx: 1. CAD: CABG 2001. Asx since, N LVEF 2. DM2 dx 2001 “mild” - gliclizide, metformin FBS: 9.1 (2004), 6.9 (Feb/06) FBS: 9.1 (2004), 6.9 (Feb/06) No Chemstrip monitoring x 2yrs No Chemstrip monitoring x 2yrs HbA1c: 4.4%, 5.8% (last 5 mo) HbA1c: 4.4%, 5.8% (last 5 mo) No known microvascular complications No known microvascular complications 3. Hypertension dx 2001: BB, HCTZ 4. Dyslipidemia – statin 5. GERD No known kidney disease, stones, BPH, UTIs. No personal/FHx of malignancy. Never smoker, no EtOH.

3. Admitted Jan 8 – 16 th to GIM service @ UAH: -4wk history of increasing leg/scrotal/hand edema -Nausea/presyncope  unresponsive  EMS: C/S=1.0 -No constitutional/CTD sx, cardioresp sx, lower urinary sx Meds: ASA 325, HCTZ 25, Metop 50, Lipitor 20, Panto 40 Metformin 500 bid, Gliclizide 80 bid Metformin 500 bid, Gliclizide 80 bid No NSAIDs/OTC, NDKA No NSAIDs/OTC, NDKA On exam: 130/82, P:70, 98% on room air. Well. 3+ edema, JVP 4 cm ASA. No rash/synovitis 3+ edema, JVP 4 cm ASA. No rash/synovitis

4. ACR= 751 P/C=1890 24hr: 20.4 g Labs: Urinalysis: 11-25 RBC, 6-10 WBC, >20 hyaline casts sAlbumin=15, N Ca/Po4, C3/C4,LFTs N. HepA,B,C –ve sAlbumin=15, N Ca/Po4, C3/C4,LFTs N. HepA,B,C –ve ANCA –ve, ANA+, dsDNA-ve, antiGBM –ve ANCA –ve, ANA+, dsDNA-ve, antiGBM –ve U/SPEP: nephrotic picture, no M-band U/SPEP: nephrotic picture, no M-band Renal u/s: Normal kidney size/echogenicity, no hydro; CXR: N

5. ACR= 751 P/C= 1800 Held oral hypoglycemics; req’d ~4U insulin/d for euglycemia Diuresed  maintenance Lasix 40 po OD Held ASA x 5 days RENAL BIOPSY: JANUARY 15 th

6. IF IgG- Moderate to strong coarsely granular capillary loop staining. IgA- Negative. IgM- Moderate irregular coarsely granular capillary loop staining. Mild mesangial staining. C3- Mild to moderate coarsely granular capillary loop staining. C1q- Negative. Kappa and lambda- Moderate coarsely granular capillary loop staining. Fibrinogen- Moderate interstitial staining. Albumin- Negative.

7. IgG

8. IgM

10. C3

11. Kappa

12. Lambda

13. Fibrin

16. Diagnosis Renal Biopsy: Membranous glomerulopathy, stage 2 with focal segmental glomerulosclerosis lesions, possibly indicating early diabetic nephropathy.